1. PULMONARY FUNCTION TESTING By: Gh. Pouryaghoub. MD Center for Research on Occupational Diseases (CROD) Tehran University of Medical Sciences (TUMS)

2. PULMONARY FUNCTION TESTS CATEGORIES Spirometry Lung volumes (TLC/ RV ) Diffusing capacity tests Blood gases and gas exchange tests Cardiopulmonary exercise tests Metabolic measurements

3. INDICATIONS FOR SPIROMETRY Detect the presence or absence of lung disease Quantify the extent of known disease Determine effects of therapy Asses risk of surgical procedures Measure effect of Occup. Or Env. Exposure Evaluate disability or impairment

4. Contraindications  Ascending aortic aneurysm  Pulmonary embolism  Myocardial infarction (1m)  Angina Hemoptysis severe HTN (systolic > 200, diastolic > 120) Pneumothorax Cerebral, thoracic or abdominal aneurysm Recent brain, eye or ear surgery Thoracic or abdominal surgery(3 w) Acute diarrhea Infection control issue

5. Confounding factors Smoking within 1 h of testing Consuming alcohol within 4 h of testing Vigorous exercise within 30 min of testing Tight clothing Large meal within 2 h of testing Chest or abdominal pain Pain in mouth or face Stress incontinence Dementia or confessional state

6. Complications Chest pain Syncope, dizziness Increased ICP Paroxysmal coughing Bronchospasm Nosocomial infection

7. Hygiene & infection control Hand washing Gloves Disposable mouth piece & nose clip Disinfection or sterilization of reusable mouth piece Extra precautions for patient with infection

8. Respiratory Volumes Tidal Volume: Amount of air moved in and out of lungs during normal breathing Inspiratory Reserve Volume: Amount of air inspired over normal tidal inspiration at maximal effort Expiratory Reserve Volume: Amount of air expired over normal tidal expiration at maximal effort Residual Volume: A ir left in lung after maximal expiration

9. Respiratory Capacities Functional Residual Capacity: ERV+RV Inspiratory Capacity: TV+IRV Vital Capacity: IRV+TV+ERV Total Lung Capacity: VC+RV

10. LUNG VOLUMES & CAPACITIES

11. Type of spirometer Volumetric spirometer Flow-type spirometer

12. Flow – Volume Curve

13. Volume - Time Curve

14. Spirometric values FVC (forced vital capacity) FEV1 (forced expiratory volume in 1 s) FEV1/FVC FEF25-75 (maximum midexpiratory flow) FEVt (forced expiratory volume in t s) PEF (peak expiratory flow)

15. Spirometry Steps Equipment performance criteria Equipment validation Subject maneuvers Acceptability Repeatability interpretation

16. Technical Sources of Variation in Lung Function Instrument (Precision and Accuracy) Effort Posture (body and head position) Observer Procedure (including number of tests) Software (calculation and feedback) Temperature Altitude

17. Biologic Sources of Variation in Lung Function Diurnal variation Seasonal effects Endocrinologic effects Personal factors Environmental factors Occupation factors

18. Within Maneuver Acceptability Criteria  Extrapolated volume  Cough especially during first second  End of test criteria  Valsalva maneuver (glottis closure)  Leak from the mouth  Obstruction of the mouthpiece  Extra breath during the maneuver

21. Between Maneuver Acceptability Criteria Three acceptable spirograms Two largest FVC within 0.150 L of each other Two largest FEV1 within 0.150 L of each other A total of eight tests or The patient cannot or should not continue

23. Are these results below the “lower limit of normal?”

24. Interpretation Predicted value & lower limit of normal (LLN)  Fifth percentile: the point below which 5% of normal subjects fall. FEV1 and FVC = 80% FEV1/FVC = 70-75% FEF25-75 = 50-60%

25. LLN for male with 175cm height AgeFVCFEV1FEV1/FVCFEF25-75 2083% 74%68% 4082%81%70%60% 6080%78%66%46% 8076%72%62%18%

26. Normal Spirometry Both the FVC and the FEV1/VC ratio are normal.

27. Obstructive Spirometry Normal or low FVC, Low FEV1 & FEV1/FVC

28. Restrictive Spirometry Low FVC & FEV1, Normal or high FEV1/FVC (TLC & RV should be measured)

29. Mixed pattern Spirometry Low FEV1, FVC, FEV1/FVC

31. The Severity of the Abnormality % Pred FEV1 > 80 Normal % Pred FEV1 70 = Mild % Pred FEV1 60 = Moderate % Pred FEV1 50 = Moderately severe % Pred FEV1 35 Severe % Pred FEV1 < 35 = Very severe